Journal Review

Anthropometric Assessment

Nutritional Assessment
Prof. Janice P. Feliciano

Submitted by:
Gabrielle C. de Leon | BSND2A-1

May 6, 2023
 Journal of Forensic and Legal Medicine
Volume 63, April 2019, Pages 1-6

Research Paper Title:

Body mass index and fatal stroke in young adults: A national study

Published by: Shane Darke, Johan Duflou, Sharlene Kaye, Michael Farrell, Julia Lappin

Abstract

Rates of stroke and obesity have increased in recent years. This study aimed to determine
the body mass index (BMI) of fatal stroke cases amongst young adults, their clinical
characteristics, and the association of BMI with risk factors. All cases aged 15–44 years where
death was attributed to stroke for whom BMI was available were retrieved from the National
Coronial Information System (1/1/2009-31/12/2016). 179 cases were identified: hemorrhagic,
ischaemic, thrombotic, mycotic, and embolic. Proportions in each BMI category were:
underweight (5.6%), normal weight (37.4%), overweight (27.4%), and obese (29.6%). There was
a significant linear trend in the proportion of subarachnoid hemorrhages as BMI increased
(p < 0.05) and between higher BMI and hypertension (p < 0.001). There were no group
differences in cardiomegaly or left ventricular hypertrophy where known causes were other than
hypertension, cardiomyopathy, severe coronary artery atherosclerosis, endocarditis, or cerebral
arteries atherosclerosis. A history of alcoholism (p < 0.01) was less likely with a higher BMI.
There was no association between BMI and previous stroke, diabetes, vasculitis,
gravid/post-partum, tobacco use, psychostimulant use, or injecting drug use. Overweight and
obese cases were prominent among young fatalities of stroke. Reducing rates of obesity, and
associated hypertension, would be expected to reduce the escalating stroke rates among young
adults.
Introduction

Stroke is a major public health problem that appears to have increased in contribution to
the global burden of disease in recent years. Between 1990 and 2010, stroke rose from fifth to
the third leading cause of disability-adjusted life years, increasing by 19% over that period.
Whilst stroke is more common amongst older adults, the incidence of stroke has been increasing
among younger adults. Rising rates of stroke amongst young adults are of particular concern as
they are, due to their age, associated with more disability-adjusted life years and, in the case of a
fatality, more years of potential life lost. The clinical characteristics of stroke appear to differ
amongst younger adults, with a greater proportion due to subarachnoid hemorrhage and
intracranial hemorrhage compared to the general stroke population.

Known risk factors amongst young adults include psychostimulant, alcohol, and tobacco
use. Injecting drug use per se is also a risk due to cardiac valvular lesions associated with
infective endocarditis. Cardiovascular disease is particularly prominent, including hypertensive
heart disease, ischaemic heart disease, cardiomyopathy, dyslipidemia, cerebrovascular
atherosclerosis, cerebral vasculitis, and diabetes-associated cardiovascular disease. For young
females, there is also increased risk during pregnancy and the puerperium, and with the use of
oral contraceptives.

One particularly prominent independent risk factor is obesity, associated with increased
risk for cardiovascular disease, and both hemorrhagic and ischaemic stroke. It has been estimated
that for each five-point increase in body mass index (BMI) the risk for stroke increases by 18%.
Consistent with this linear relationship, overweight and obese individuals have the greatest risk
for both hemorrhagic and ischaemic stroke, with the highest rates being seen in the obese.
Indeed, the relative risk for stroke associated with obesity appears to be higher among younger
adults compared with older individuals and is associated with higher mortality. The major
mediator of the association between higher BMI and stroke risk is believed to be hypertension,
with a linear association reported between BMI and the likelihood of cardiovascular disease.
This association is of particular concern, as rates of obesity have increased markedly amongst
young adults in recent years.

Stroke amongst young adults is clearly a major clinical issue, and fatal stroke amongst
this population represents a substantial loss of potential life. The role of BMI in such cases is not
known as, to date, no large case series has examined BMI in cases of fatal stroke amongst young
adults. In this study, we present a national case series of fatal strokes that came to the attention of
a coroner, their BMI profiles, their clinical characteristics, and evidence from autopsy or clinical
histories for other known risk factors. Specifically, the study aimed to:
 ​ 1. Determine the BMI profiles of cases of fatal stroke amongst young adults in Australia,
2009–2016;
​ 2. Determine the clinical characteristics of fatal stoke amongst young adults and their
relationship to BMI; and
​ 3. Determine the association of known risk factors with BMI.

Section snippets

National Coronial Information System

The National Coronial Information System (NCIS) is a database of coronial information

as provided by the coroners' courts in each Australian jurisdiction. A complete NCIS case file
includes demographic information, a police narrative of circumstances, autopsy reports,
toxicology reports, and the coronial finding. The cause of death is ascertained by a forensic
pathologist and documented on the autopsy and coroner's report. The forensic pathologist may
report on i. the direct cause of death, ii. the..

Case characteristics

There were 280 cases across the study period where the direct or antecedent cause of
death was stroke, of which BMI data were available on 179 (63.9%) and included in this study.
The mean age of cases was 37.0 yrs (SD 6.2, range 17–44 yrs), and 50.3% were male (Table 1).
Neither age (F3,175 = 1.9, p = 0.1) nor sex (χ23 = 5.4, p = 0.1) differed across groups.

The mean BMI was in the overweight range. Proportions in each BMI category were:
underweight (5.6%), normal weight (37.4%), and overweight.

Discussion:

The current study presents the first national data, and the largest case series, on BMI and
fatal stroke amongst young adults. Over half of the cases were either overweight or obese, and
close to a tenth were morbidly obese. Overall, the BMI profiles of cases were higher than
expected for the age of the population, and the average BMI was in the overweight range.
Importantly, the BMI profile was not associated with either age or sex. Consistent with other
studies of stroke in young adults hemorrhagic.
Journal Review:

Obesity and stroke rates have grown recently. In this study, the body mass index (BMI),

clinical features, and relationships between BMI and risk variables were investigated in fatal

stroke cases among young individuals. The National Coronial Information System was queried

for all cases ages 15–44 years old, where the stroke was the cause of death and BMI was known.

Hemorrhagic, ischemic, thrombotic, mycotic, and embolic instances totaling 179 were found.

Underweight (5.6%), normal weight (37.4%), overweight (27.4%), and obese (29.6%) were the

proportions in each BMI category. There was a strong linear trend between higher BMI and

hypertension as well as between higher BMI and the proportion of subarachnoid hemorrhages.

In cases of cardiomegaly or left ventricular hypertrophy with recognized causes other

than hypertension, cardiomyopathy, severe coronary artery atherosclerosis, endocarditis, or

cerebral artery atherosclerosis, there were no differences between the groups. A higher BMI

decreased the likelihood of having a history of alcoholism. There was no correlation between

BMI and prior stroke, diabetes, vasculitis, being pregnant or postpartum, using tobacco or

psychostimulants, or using injectable drugs. Young people who died from a stroke frequently had

weight and obesity issues. The rising stroke incidence among young adults would be anticipated

to be decreased by lowering obesity and its accompanying hypertension.

The current study includes the largest case series and the first nationwide data on BMI

with fatal stroke in young adults. Nearly one in ten of the cases were morbidly obese, with over

half of those being either overweight or obese. In general, the BMI profiles of the patients were

higher than would be predicted given the population's age, and the average BMI was in the

overweight range. Importantly, neither age nor sex was connected to the BMI profile.

Hemorrhagic stroke in young individuals is consistent with prior research.